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Harmonize for Speech, Hearing & Language Clinic55261484006443954780342265Adult Speech-Language Intake Form869315324485DO YOU NEED HELP FILLING OUT THIS FORM? □YES □ NO Today’s date: _______________________________________________-12065179705Last Name: 23495179705First Name:-60960183515Address: City: Postal Code:-63621192960Telephone #: ( ) ____ - ____________-53340194945Email Address:41111264160Date of Birth: 153733521242180010201295Gender: □Female □Male 44577019812043815198755Emergency Contact Person:35623519812022860198120Contact Person’s Phone #: ( ) ____ - ____________-3810183515Present/ Past Occupation: 89535240665Highest Level of Education: 60960258445First Language: -2351174598Other Languages Spoken:484267234261716821154267202043647-166505PHYSICIAN INFORMATION Family Physician’s name: __________________________ Phone: ( ) ____ - _________3826348720365Other physicians involved in your care: ____________________________________________________________________________________________3000768150548MEDICAL HISTORY (Related to the Communication Difficulty) Date of occurrence for difficulty / injury/ illness: ________________________________________________Cause of Difficulty/ Injury/ Illness:279400321945Accident274320269875Brain Injury36688187981Stroke7080253175Disease Type:_________________Other:____________________________________4062095227330Please list any medications that you are currently taking:8597902844803740042474426ALLERGIES 40963856978655491480680085278638038100Do you have any allergies? □YES □ NO 663003512700If yes, please list them. Do you use an Epi Pen? □YES □ NODo you have any other medical concerns? (Example: epilepsy, seizures, paralysis, migraines) COMMUNICATION DIFFICULTIESCommunication Difficulty259620-46409YES 222587-14795NO SOMETIMES2990742-33223Friends & family can’t understand my speech 115029511696Difficulty hearing 1484569-63795Difficulty finding words 12788464445My speech is slow 1459717-1285My voice has changed 7042302540Stuttering2432050-3810Difficulty getting my thoughts out 134329235281316385975918Swallowing difficultiesMemory or thinking Other:39014402584455281295278130Have you had a speech-language assessment? □YES □ NO3921084372799If yes, where and when? _________________________________________________________52571656985Have you had previous speech-language therapy? □YES □ NO If yes, where and when? _________________________________________________________Do you, or have you ever had, problems with feeding?Swallowing12001543815-3810309245DroolingChewingCoughingChokingOther:____________________________SPEECH How do you usually communicate?□Gestures □Single words□Short phrases □Sentences □No problems □Other: ______________________________________________________59956701524002997835219075607695187960Please check any supportive aids that you use:2839720434975774700372745□Cane □Walker □Wheelchair □Dentures □Eye glasses□Other _______________________________ 39996182595451701165153035Please check any communication aids that you use: 2826042282563455993541592510915654114806141720-95250□Communication device □Alphabet/picture board □Sign language□Paper and pen □ iPad □ Cell phone□Other __________________ 4057652914652247265323215Which hand do you use for writing? LeftRight46504733261152806280376555HEARING DIFFICULTIES46330003999932730500497840Do you have hearing difficulties: □YES □ NOHave you ever had a hearing test? □Yes □ No46894753314703699510337185If yes, where and when? _________________________________________________________32670754533901908810454660If no, do you have any concerns about your hearing? □Yes □ NoDo you wear a hearing aid? □Yes □ No3884590-1160404851121-46516007683-1251Has your communication difficulty affected your social life? □Yes □ NoIf yes, please explain: ________________________________________________________________________________________________________________________________________________________________________________________What are your hobbies & interests? Are you involved in any group activities? 2950615762732________________________________________________________________________________________________________________________________________________________________________________________3264313250344What are your preferences in reading material? __________________________________________ What are your preferences in TV/entertainment? __________________________________________1750420136541Have there been any changes in mood, personality, ability to care for self since the occurrence of your difficulty / injury/ illness? ________________________________________________________________________________________________________________________________________________________________________________________Is there any additional information that would help us to better understand the nature of your communication difficulty?________________________________________________________________________________________________________________________________________________________________________________________578421548768048717205295905382620516150Please list any community supports/referrals/professional agencies involved in your care. (Example: Brain Injury Services, CCAC, Occupational Therapist, Physiotherapist, Social Worker, Registered Dietician, Neurologist.) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Thank You!We thank you for your time, and the care with which you filled out this form. This intake form will be reviewed by our clinic Speech-Language Pathologist (SLP) and Communicative Disorders Assistant (CDA) students and will be a reference for them in planning your therapy services at our clinic.While we strive to provide all clients with the therapy services that they desire, we would like you to keep two things in mind:All clients seeking therapy services at this clinic must have had a formal speech-language assessment completed prior to starting therapy in this clinic.This is a teaching clinic and there will be times during therapy sessions where our CDA students will be receiving direction from our clinic SLP.We appreciate your patronage, and look forward to helping you and your loved ones.The Faculty SLP Clinician(s), CDA students, and Staffof the Harmonize for Speech, Hearing & Language Clinic ................
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